I 

118TH CONGRESS 

2D SESSION H. R. 9125 

To amend title XVIII of the Social Security Act to improve the accuracy 

and predictability of Medicare payments to long-term care hospitals. 

IN THE HOUSE OF REPRESENTATIVES 

JULY 24, 2024 

Mrs. MILLER of West Virginia (for herself, Ms. VAN DUYNE, Mr. SMUCKER, 

Mr. SMITH of Nebraska, and Mr. JOYCE of Pennsylvania) introduced the 

following bill; which was referred to the Committee on Ways and Means 

A BILL 

To amend title XVIII of the Social Security Act to improve 

the accuracy and predictability of Medicare payments 

to long-term care hospitals. 

1 Be it enacted by the Senate and House of Representa2 tives of the United States of America in Congress assembled, 

3 SECTION 1. SHORT TITLE. 

4 This Act may be cited as the ‘‘Patient Access to 

5 LTCH Care Act’’. 


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1 SEC. 2. ENSURING ADEQUACY OF PAYMENTS FOR HIGH2 ACUITY LONG-TERM CARE HOSPITAL PA3 TIENTS. 

4 (a) IN GENERAL.—Section 1886(m)(7) of the Social 

5 Security Act (42 U.S.C. 1395ww(m)(7)) is amended— 

6 (1) in subparagraph (B)— 

7 (A) by striking ‘‘Notwithstanding subpara8 graph (A)’’ and inserting the following: 

9 ‘‘(i) IN GENERAL.—Notwithstanding 

10 subparagraph (A)’’; and 

11 (B) by adding at the end the following new 

12 clause: 

13 ‘‘(ii) LIMITATION ON INCREASE OF

14 FIXED LOSS AMOUNT.—Notwithstanding 

15 clause (i)— 

16 ‘‘(I) in the case that application 

17 of such clause would result in a fixed 

18 loss amount established for fiscal year 

19 2025 or 2026 that is greater than 

20 $50,000, the Secretary shall set such 

21 fixed loss amount for such fiscal year 

22 at $50,000; and 

23 ‘‘(II) in the case that application 

24 of such clause would result in a fixed 

25 loss amount established for fiscal year 

26 2027 or a subsequent fiscal year that 


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1 is greater than 110 percent of the 

2 fixed loss amount established for the 

3 preceding fiscal year, the Secretary 

4 shall set such fixed loss amount for 

5 such fiscal year at 110 percent of the 

6 fixed loss amount established for the 

7 preceding fiscal year.’’; and 

8 (2) in subparagraph (C), by striking ‘‘reduc9 tion’’ and inserting ‘‘change’’. 

10 (b) PAYMENT ADJUSTMENT FOR COMPLEX LONG11 TERM CARE HOSPITAL PATIENTS.—Section 1886(m) of 

12 the Social Security Act (42 U.S.C. 1395ww(m)) is amend13 ed by adding at the end the following new paragraph: 

14 ‘‘(8) PAYMENT ADJUSTMENT FOR PATIENTS

15 WITH COMPLICATIONS OR COMORBIDITIES OR MAJOR

16 COMPLICATIONS OR COMORBIDITIES.— 

17 ‘‘(A) IN GENERAL.—For discharges occur18 ring on or after October 1, 2025, or such ear19 lier date as the Secretary may specify, the Sec20 retary shall increase payment rates under the 

21 system described in paragraph (1) in accord22 ance with subparagraph (B) to fully account for 

23 the higher costs associated with treating the 

24 highest complexity individuals. 


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1 ‘‘(B) INCREASE.—In calculating payment 

2 rates under the system described in paragraph 

3 (1) for a discharge of an individual occurring 

4 on or after October 1, 2025 (or such earlier 

5 date as the Secretary may specify), the Sec6 retary shall— 

7 ‘‘(i) in the case such individual had 

8 more than 5 major complications or 

9 comorbidities and fewer than 6 complica10 tions or comorbidities that were not major 

11 or had between 3 and 5 major complica12 tions and comorbidities and 5 or more 

13 complications and comorbidities that were 

14 not major (as demonstrated by claims data 

15 on the claim form submitted by the long16 term care hospital), increase the payment 

17 weight for the applicable diagnosis-related 

18 group by 5 percent; and 

19 ‘‘(ii) in the case such individual had 

20 more than 5 major complications or 

21 comorbidities and more than 5 complica22 tions or comorbidities that were not major 

23 (as so demonstrated), increase the pay24 ment weight for the applicable diagnosis25 related group by 10 percent. 


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1 ‘‘(C) ASSUMPTIONS AND ADJUSTMENTS.— 

2 ‘‘(i) IN GENERAL.—The Secretary 

3 shall annually determine the impact of 

4 ICD–10 coding changes on aggregate 

5 spending as a result of the application of 

6 the payment increases under subparagraph 

7 (A) with respect to fiscal years 2026 

8 through 2030. 

9 ‘‘(ii) PERMANENT ADJUSTMENTS.— 

10 The Secretary shall, at a time and in a 

11 manner determined appropriate by the 

12 Secretary, through notice and comment 

13 rulemaking, provide for one or more per14 manent increases or decreases to the 

15 standard prospective payment amount (or 

16 amounts) for fiscal years referenced in 

17 clause (i), on a prospective basis, to offset 

18 for increases or decreases in aggregate ex19 penditures associated with coding changes 

20 attributable to the application of the pay21 ment increases under subparagraph (A). 

22 ‘‘(iii) TEMPORARY ADJUSTMENTS FOR

23 RETROSPECTIVE BEHAVIOR.—The Sec24 retary shall, at a time and in a manner de25 termined appropriate by the Secretary, 


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1 through notice and comment rulemaking, 

2 provide for one or more temporary in3 creases or decreases to the standard pro4 spective payment amount (or amounts) for 

5 fiscal years referenced in clause (i). Such 

6 a temporary increase or decrease shall 

7 apply only with respect to the fiscal year 

8 for which such temporary increase or de9 crease is made, and the Secretary shall not 

10 take into account such a temporary in11 crease or decrease in computing such 

12 amount under this subsection for a subse13 quent fiscal year. 

14 ‘‘(D) NONAPPLICATION OF BUDGET NEU15 TRALITY.—The additional payments resulting 

16 from the application of this paragraph shall not 

17 be implemented in a budget neutral manner.’’. 

18 SEC. 3. SAFEGUARDING SERVICES FOR LONG-TERM CARE 

19 HOSPITAL PATIENTS WITH CERTAIN COM20 PLEX CONDITIONS. 

21 Section 1886(m)(6) of the Social Security Act (42 

22 U.S.C. 1395ww(m)(6)) is amended— 

23 (1) in subparagraph (A)— 

24 (A) in clause (i), by striking ‘‘and (G)’’ 

25 and inserting ‘‘(G), and (H)’’; 


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1 (B) in clause (iii)(I), by inserting ‘‘or, with 

2 respect to discharges from a long-term care 

3 hospital occurring on or after October 1, 2023, 

4 by a discharge from a stay in a critical access 

5 hospital,’’ after ‘‘from a subsection (d) hos6 pital’’; and 

7 (C) in clause (iv)(I), by inserting ‘‘for dis8 charges from a long-term care hospital occur9 ring before October 1, 2023,’’ before ‘‘the stay 

10 in the long-term care hospital’’. 

11 (2) by adding at the end the following new sub12 paragraph: 

13 ‘‘(H) ADDITIONAL EXCEPTION FOR PA14 TIENTS WITH CERTAIN COMPLEX CONDI15 TIONS.— 

16 ‘‘(i) IN GENERAL.—For a discharge in 

17 a cost reporting period beginning on or 

18 after October 1, 2023, subparagraph (A)(i) 

19 shall not apply (and payment shall be 

20 made to a long-term care hospital without 

21 regard to this paragraph) if such dis22 charge— 

23 ‘‘(I) meets either of the criteria 

24 described in clause (ii); and 


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1 ‘‘(II) does not have a principal 

2 diagnosis relating to a psychiatric di3 agnosis or to rehabilitation. 

4 ‘‘(ii) CRITERIA DESCRIBED.—For pur5 poses of clause (i), the criteria described in 

6 this clause are, with respect to a discharge 

7 of an individual from a long-term care hos8 pital, the following: 

9 ‘‘(I) The stay in the long-term 

10 care hospital ending with such dis11 charge was immediately preceded by a 

12 discharge from a stay in a subsection 

13 (d) hospital or a critical access hos14 pital and— 

15 ‘‘(aa) such individual was 

16 treated at the long-term care 

17 hospital for a severe wound (as 

18 defined in clause (iii)); 

19 ‘‘(bb) such discharge from 

20 such long-term care hospital is 

21 assigned to Medicare-Severity22 Long-Term-Care-Diagnosis-Re23 lated-Group (MS–LTC–DRG) 

24 189 relating to pulmonary edema 


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1 and respiratory failure (or any 

2 successor MS–LTC–DRG); 

3 ‘‘(cc) such discharge from 

4 such long-term care hospital is 

5 assigned to MS–LTC–DRG 871 

6 relating to septicemia or severe 

7 sepsis without mechanical ven8 tilation greater than 96 hours 

9 with major complications or 

10 comorbidities (or any successor 

11 MS–LTC–DRG); or 

12 ‘‘(dd) such individual was 

13 treated at the long-term care 

14 hospital for COVID–19. 

15 ‘‘(II) The discharge from such 

16 long-term care hospital is assigned to 

17 a MS–LTC–DRG with a relative 

18 weight that is equal to or greater than 

19 the specified amount (as defined in 

20 clause (iii)) for the fiscal year in 

21 which such discharge occurred. 

22 ‘‘(iii) DEFINITIONS.—In this subpara23 graph: 

24 ‘‘(I) SEVERE WOUND.—The term 

25 ‘severe wound’ means a stage 3 


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1 wound, stage 4 wound, unstageable 

2 wound, non-healing surgical wound, 

3 infected wound, fistula, osteomyelitis, 

4 or a wound with morbid obesity, as 

5 identified by applicable codes on the 

6 claim from the long-term care hos7 pital. 

8 ‘‘(II) SPECIFIED AMOUNT.—The 

9 term ‘specified amount’ means, with 

10 respect to fiscal year, an amount 

11 equal to the 80th percentile of the rel12 ative weights for MS–LTC–DRGs 

13 that were assigned to primary diag14 noses for all discharges occurring in 

15 the preceding fiscal year. 

16 ‘‘(III) WOUND.—The term 

17 ‘wound’ means as an injury involving 

18 division of tissue or rupture or the in19 tegument or mucous membrane with 

20 exposure to the external environ21 ment.’’. 

Æ 


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